March 2016
Contents
1.0 Introduction ……………………………………………………………………………………………….3
2.0 The Decision to Refer ………………………………………………………………………………...5
3.0 Completing the Referral Form ………………………...... 6
3.1 Patient’s Details
3.2 Patient’s General Medical Practitioner (GMP) Details
3.3 The Referring GDP’s Details
3.4 History of Presenting Complaint
3.5 Minor Oral Surgery Procedures Requested
3.6 Radiographs
3.7 Medical History
3.8 Supporting Details/Other Relevant Information
3.9 NHS/Private Patients
3.10 Signature of Referring Dentist
4.0 Sending the Referral ……………………………………………………………………………….12
5.0 Referral Pathway ……………....…………………………………………………………………..13
5.1 Requirements for Eligibility to Tier 2 Services
5.2 Patient allocation
5.3 Patient Information
References …………………………………………………………………………………………………….16
Contact details – NHS England ……………………………………………………………………….16
Appendices
Appendix 1 – Referral form
Appendix 2 – Case Allocation Criteria
Appendix 3 – Bisphosphonate Guidance
Appendix 4 – Anticoagulant Therapy Guidance
1.0 Introduction
NHS England–Lancashire and its legacy PCTs have reviewed the nature of referrals made from Dental Practices to hospital/secondary care. This review has included referrals for procedures that are too complex to be carried out in Primary Dental Care as well as referrals for procedures that would normally be expected to be undertaken within Primary Dental Care. Subsequently, NHS England has commissioned extra services that will incorporate community based minor oral surgery services (MOSS) for patients. The overall aim is to ensure that patients receive an appropriate service in a suitable environment. This service is for suitable patients aged 16 years and above who require onward referral to oral surgery procedures.
General Dental Practitioners (GDPs) are required to use the Lancashire Tier 2 MOS Service Referral Form (Appendix 1). This should be accompanied by relevant radiographs of good diagnostic quality. The referrals will be processed by triage clinicians who have been accredited as and trained as performers for the MOS service. Cases will be assigned for care based upon allocation criteria (Appendix 2) which have been developed using national guidance and other key documents. The case allocation takes into account the patient’s medical history and any other modifying factors. NHS England - Lancashire will monitor all referrals including those for requests for procedures considered to be within the generally accepted competence of a GDP. This will help to identify any training needs.
NHS England - Lancashire will monitor all referrals including those for requests for procedures considered to be within the generally accepted competence of a GDP. This will help to identify any training needs.
This guidance has been developed to aid GDPs when referring adult patients for oral surgery treatment or case management outside of their practice. The guidance is presented in colour coded sections to allow easy access to the information within and it covers the following:
· The decision to refer (pink section)
· How to refer, including ‘How to complete the referral form’ (blue section)
· How to send the referral form (yellow section)
· The referral pathway (green section)
Figure 1 – Referral Pathway
2.0 The Decision to Refer
All referrals must be made in accordance with the referral criteria set out in this guidance. Personal Dental Service (PDS)/General Dental Service (GDS) agreement/contract providers are reminded of their requirement to offer the full range of mandatory services, including surgical treatment when appropriate. Before referring a patient, GDS/PDS providers should review the skill mix amongst their performers and develop a system of referral between colleagues within the practice to manage all patients requiring mandatory services in accordance with the requirements of the provider. Referrers should consult Appendix 2, Table 1 for a list of procedures that should be directed to Tier 2, MOS Services.
The responsibility for making an appropriate referral rests with the referring GDP. This guidance should not be interpreted as an instruction to individual practitioners as to what procedures they should undertake. Individual performers should only work within their knowledge, acquired skills, professional competence and clinical ability. Providers (and their performers) are encouraged to discuss any potential training needs with NHS England-Lancashire or Health Education England North West .
All referrals for oral surgery (with the exception of special needs patients who require referral to special care services) and related oral conditions from GDPs should be referred using this process as per the details in this guidance unless cancer is suspected or the patient has an immediate life threatening condition (as detailed below).
Referrals will only be processed if sent on a NHS England - Lancashire Oral Surgery Referral Form (Appendix 1). Referral forms should be accompanied, where required, by appropriate, relevant and recent radiographs, digital or otherwise, or scanned/photographic images of radiographs which must be of good diagnostic quality. Radiographs or images should be labelled with the patient’s name; date of birth; the date the radiograph was taken; and the location at which the radiograph was taken.
Failure to submit appropriate radiographs or radiographic images of an acceptable diagnostic quality will lead to the return of the referral and subsequent delay in providing appropriate care for patients.
Referrals will be processed by the Dental Referral Management Centre and triaged through the local clinical triage element of the MOSS. Patients will be allocated to receive care in either the primary care based MOSS or hospital/secondary care taking into account the relevant clinical information provided, medical history and any other modifying factors.
3.0 Completing the Referral Form
NHS England – Lancashire Oral Surgery Referral Form must be used for all adult minor oral surgery referrals (including secondary care). The only exception is for special needs patients who require the special care service to meet their needs (please see the referral pathway for special care patients). All relevant sections of the referral form must be fully completed and where possible, sent electronically by the referring GDP to the Dental Referral Mangement Centre. GDPs who do not have access to computers should discuss how they can refer into the system with the Dental Referral Management Centre by contacting 0845 862 0841
All the information fields on the referral form allow the user to select (tick box) or type in (free text boxes)/download the relevant information from their clinical system. The following information should be completed for all referrals unless otherwise stated:
3.1 Patient’s Details
· Full name
· Gender
· Date of birth and age at referral
· NHS number (where available – this can be accessed from the online version of the referral management system and enables rapid and accurate patient data entry)
· Full address and full postcode
· Current daytime telephone number (home/work/mobile), email address and preferred method of contact
· Please let the Dental Referral Management Centre and the provider know if the patient consents to bein contacted by SMS text message on their mobile phone
· Ethnic category (desirable information to). This is the ethnicity of the patient being referred as specified by the patient.
3.2 Patient’s General Medical Practitioner (GMP) Details
· GMP’s name
· The GMP’s practice address
3.3 The Referring GDP’s Details
· GDP’s name
· GDP’s practice address and telephone number
· GDP’s Performer Number
· GDP practice “V” code
· GDP GDC number
· GDP’s Email Address (if available)
Please note that if you use the online referral system the majority of these details are recorded so they do not need to be re-entered. You can simply eneter your GDC and performer number once. The pratice V code will be associated with the practice login.
3.4 History of Presenting Complaint
For all referrals, the referring GDP must provide a history of the presenting complaint and give details of any attempted procedures or any treatment already undertaken. The referring GDP must also clearly indicate on the referral form the procedure requested and/or the reason for referral.
3.5 Minor Oral Surgery Procedures Requested
Procedures involving oral soft or hard tissue likely to compromise major nerves
This box must be selected if the oral surgery procedure or the management of the oral condition requested is likely to compromise major nerves. The supporting detail box on page 2 of the referral form must be used to provide additional information about the relationship to the major nerves that could be compromised.
Surgical removal of teeth/roots
This box must be selected if surgical removal of teeth/roots is required. It is expected that, in the absence of complicating factors, the vast majority of surgical exodontia (extractions, fractured teeth, visible roots etc) should take place in primary care, including the raising of buccal/labial flaps and removal of bone if required. The need for multiple extractions is not, in itself, a reason for referral.
The supporting detail box on page 2 of the referral form must be used to provide additional information clearly explaining why the procedure cannot be provided by the referring GDP or by another practitioner within the practice.
Surgical removal of impacted wisdom teeth
This box must be selected if the surgical removal of an impacted wisdom tooth or impacted wisdom teeth is required. Partially erupted/impacted third molars should only be referred for removal in accordance with National Institute of Clinical Excellence guidelines1. This states that wisdom teeth removal should be limited to patients with evidence of pathology.
Such pathology includes:
· un-restorable caries
· non-treatable pulpal and/or periapical pathology
· cellulitis, abscess and osteomyelitis
· internal/external resorption of the tooth or adjacent teeth
· fracture of tooth
· disease of follicle including cyst/tumour
· recurrent episodes of pericoronitis
The supporting detail box on page 2 of the referral form must be used to provide additional information explaining the reason for referral.
Management of cysts of the jaws
This box must be selected if referring a patient for the management of a cyst of the jaws. The supporting detail box on page 2 of the referral form must be used to provide additional information about the condition such as the location, size, structures affected or in close proximity.
Apicectomy
This box must be selected if apicectomy is required. These should only be referred in accordance with the Royal College of Surgeons (England) Faculty of Dental Surgery Guidelines for Surgical Endodontics2. In summary, referrals should only be sent where:
1. There is periradicular disease associated with a tooth where iatrogenic or developmental anomalies prevent non-surgical root canal treatment being undertaken.
2. There is periradicular disease in a root-filled tooth where non-surgical root canal retreatment cannot be undertaken or has failed, or when it may be detrimental to the retention of the tooth
3. Where a biopsy of periradicular tissue is required.
4. Where visualisation of the periradicular tissues and tooth root is required
when perforation or root fracture is suspected.
5. Where it may not be expedient to undertake prolonged nonsurgical root canal retreatment because of patient considerations.
Apicectomies will not be provided on molar teeth unless there are exceptional circumstances. The tooth to be apicected should have optimal periodontal health with no mobility and should be restorable following surgery. Poor oral hygiene, a high uncontrolled caries rate and untreated periodontal disease elsewhere in the mouth are also contra-indications to referral for apicectomies. The supporting detail box on page 2 of the referral form must be used to provide additional information about the tooth and the request or apicectomy.
Surgical exposure of tooth/teeth (at the request of orthodontic specialist)
This box must be selected if the surgical exposure of tooth/teeth at the request of orthodontic specialist is required. The supporting detail box on page 2 of the referral form must be used to provide additional information clearly explaining the request from the orthodontic specialist. Ensure a copy of the orthodontist letter is enclosed.
Removal of non suspicious soft tissue lesion (fully describe size, site, appearance and nature)
This box must be selected if referring a patient for the management of non-suspicious soft/hard tissue lesions. Those lesions that, in the judgement of the referring dentist require investigation and/or management in hospital/secondary care should still be referred using the Lancashire Oral Surgery Referral Form, except in case of suspicious or unexplained soft and hard tissues where malignancy is suspected.
The supporting detail box on page 2 of the referral form must be used to provide additional information including a description of the characteristics of the lesion such as the nature, size, site and appearance. A photograph should be included if possible.
Other Minor Oral Surgery procedures considered by referrer to be beyond the competence of any performer within the provider’s contract
A patient may have to be referred for a simple minor oral surgery procedure because of modifying factors (see the other relevant information section). If a patient is being referred for a simple minor oral surgery procedure but there are no modifying factors nor uncontrolled medical conditions, then this box must be selected to indicate that the procedure is considered by referrer to be beyond the competence of any performer within the provider’s contract. The supporting detail box on page 2 of the referral form must be used to provide additional information clearly explaining why the procedure cannot be provided by the referring GDP or by another practitioner within the practice.
3.6 Radiographs
All referrals for hard and/or soft tissue procedures must include digital radiographs or radiographic images as appropriate. Radiographs are required for all surgical extractions and apicectomies. In circumstances where a dental extraction has been incomplete, i.e fractured, a post operative radiograph showing the retained portion in its entirety must be included with the referral.
An OPT is required for procedures involving lower third molars and those procedures likely to compromise the inferior dental nerve. For procedures involving other teeth a periapical radiograph, showing the whole tooth including the crown and the root will be required.
The digital radiographs or radiographic images sent with the referral form must be relevant, recent and of appropriate quality for diagnosis/treatment.
Digital radiographs or images should be in standard image JPEG format. All radiographs should be labelled with the patient’s name; date of birth; the date the radiograph was taken; and the location at which the radiograph was taken. If an OPT has been taken in a hospital this should be recorded on the referral form in the appropriate place.